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  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:extend>
    <div class="row-fluid">
        <div class="span12">
            <h1 class="pageTitle">Specifieke gegevens</h1>
        </div>
    </div>
    <div class="row-fluid form-horizontal">
        <fieldset>

            <wicket:container wicket:id="paspoort"></wicket:container>

            <form wicket:id="form">
                <wicket:container wicket:id="specifiekeContactInformatie"></wicket:container>
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Organisatie gerelateerde instellingen</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label type="text" class="control-label">Regiocode (2
                                    letterig)</label>
                                <div class="controls">
                                    <input wicket:id="regioCode" class="input-large" type="text"
                                           value="" maxlength="2">
                                </div>
                            </div>
                            <div class="control-group">
                                <label type="text" class="control-label">FITretour
                                    percentage</label>
                                <div class="controls">
                                    <input wicket:id="ifobtRetourPercentage" class="input-large"
                                           type="text" value="25"> %
                                </div>
                            </div>
                            <div class="row-fluid">
                                <div class="span12">
                                    <label class="control-label" type="text">Logo
                                        (Minigrip)</label>
                                    <div class="controls">
                                        <wicket:container wicket:id="logo"></wicket:container>
                                    </div>
                                </div>
                            </div>
                            <div class="row-fluid">
                                <div class="span12">
                                    <label class="control-label" type="text">Logo (Brieven)</label>
                                    <div class="controls">
                                        <wicket:container wicket:id="logoBrief"></wicket:container>
                                    </div>
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label" type="text">Kwaliteitslogo
                                </label>
                                <div class="controls">
                                    <wicket:container wicket:id="kwaliteitslogo"></wicket:container>
                                </div>
                            </div>
                            <div class="row-fluid">
                                <div class="span12">
                                    <label class="control-label" type="text">Handtekening
                                        Bestuurder</label>
                                    <div class="controls">
                                        <wicket:container wicket:id="besturderSign"></wicket:container>
                                    </div>
                                </div>
                            </div>
                            <div class="row-fluid">
                                <div class="span12">
                                    <label class="control-label" type="text">Handtekening
                                        Rcmdl</label>
                                    <div class="controls">
                                        <wicket:container wicket:id="rcmdlSign"></wicket:container>
                                    </div>
                                </div>
                            </div>

                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Regionaal coördinerend MDL
                                    arts</label>
                                <div class="controls">
                                    <input wicket:id="rcmdl" class="input" type="text" value=""
                                           name="rcmdl">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label" type="text">Rechtbank</label>
                                <div class="controls">
                                    <input wicket:id="rechtbank" class="input" type="text" value=""
                                           name="rcmdl">
                                </div>
                            </div>
                            <div class="row-fluid">
                                <div class="span6">
                                    <div class="control-group">
                                        <label class="control-label">Vertegenwoordiger</label>
                                        <div class="controls">
                                            <textarea wicket:id="vertegenwoordiger"></textarea>
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>
                <fieldset wicket:id="borstkankerGegevens">
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Borstkanker gegevens</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span12">
                            <div class="control-group">
                                <label class="control-label">Afspraakdrempel </label>
                                <div class="controls">
                                    <input wicket:id="afspraakDrempelBk"
                                           class="afspraakDrempel input-large" type="text" maxlength="3"
                                           onchange="deVoorspellingsgrafiekenDeelnamekans.onAfspraakDrempelChange()"/> %
                                </div>
                            </div>
                            <div id="voorspellingsgrafiekDeelnamekansDiv">
                                <input type="hidden" wicket:id="applicationUrl" class="applicationUrl"/>
                                <input type="hidden" wicket:id="subUrl" class="subUrl"/>
                                <svg id="voorspellingsgrafiekDeelnamekans"/>
                                <svg id="voorspellingsGrafiekMatrix1"/>
                                <svg id="voorspellingsGrafiekMatrix2"/>
                            </div>
                            <script src="assets/js/voorspellingsgrafiek/util.js"></script>
                            <script src="assets/js/voorspellingsgrafiek/data.js"></script>
                            <script src="assets/js/voorspellingsgrafiek/rij.js"></script>
                            <script src="assets/js/voorspellingsgrafiek/matrix.js"></script>
                            <script src="assets/js/voorspellingsgrafiek/voorspellingsgrafiek.js"></script>

                            <fieldset>
                                <div class="row-fluid">
                                    <div class="span12">
                                        <legend>Factoren</legend>
                                    </div>
                                </div>
                                <div class="row-fluid">
                                    <div class="span4">
                                        <div class="control-group">
                                            <label class="control-label">Eerste onderzoek</label>
                                            <div class="controls">
                                                <input wicket:id="factorEersteOnderzoekBk" class="input-large" type="text" maxlength="4">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="span4">
                                        <div class="control-group">
                                            <label class="control-label">Dubbele tijd (incl. tehuis)</label>
                                            <div class="controls">
                                                <input wicket:id="factorDubbeleTijdBk" class="input-large" type="text" maxlength="4">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="span4">
                                        <div class="control-group">
                                            <label class="control-label">Mindervalide (incl. tehuis)</label>
                                            <div class="controls">
                                                <input wicket:id="factorMinderValideBk" class="input-large" type="text" maxlength="4">
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </fieldset>
                            <fieldset>
                                <div class="row-fluid">
                                    <div class="span12">
                                        <p>
                                            In de planning worden intervallen geprognotiseerd. Daarvoor moet bekend zijn hoeveel weken voor de afspraak mensen gemiddeld worden
                                            uitgenodigd.
                                        </p>
                                    </div>
                                </div>
                                <div class="row-fluid">
                                    <div class="span6">
                                        <div class="control-group">
                                            <label class="control-label">Uitnodigen</label>
                                            <div class="controls">
                                                <input wicket:id="wekenVanTevorenUitnodigen" type="number" maxlength="1"/> weken van tevoren
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </fieldset>
                            <fieldset>
                                <div class="row-fluid">
                                    <div class="span6">
                                        <div class="control-group">
                                            <label class="control-label">Minimale dagcapaciteit voor mindervalide afspraken</label>
                                            <div class="controls">
                                                <input wicket:id="minimaleDagCapaciteitMinderValideAfspraken" type="number"/>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </fieldset>

                            <wicket:container wicket:id="ceBeSeOverzicht"/>

                        </div>
                    </div>
                </fieldset>
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Financi&euml;le gegevens</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">IBAN <i class="icon-asterisk icon-purple"></i></label>
                                <div class="controls">
                                    <input wicket:id="iban" class="input-large" type="text">
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Tenaamstelling <i
                                        class="icon-asterisk icon-purple"></i></label>
                                <div class="controls">
                                    <input wicket:id="ibanTenaamstelling" class="input-large" type="text">
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>E-Novation Gegevens</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Klantnummer</label>
                                <div class="controls">
                                    <input class="input" type="text" value=""
                                           wicket:id="enovationKlantnummer"/>
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">EDI-adres</label>
                                <div class="controls">
                                    <input class="input" type="text" value=""
                                           wicket:id="enovationEdiAdres"/>
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>

                <wicket:enclosure child="retouradressen">
                    <fieldset>
                        <div class="row-fluid">
                            <div class="span12">
                                <legend>Retouradressen ZAS per BMHK laboratorium</legend>
                            </div>
                        </div>
                        <div class="row-fluid">
                            <div class="span12">
                                <table class="table table-bordered table-condensed">
                                    <thead>
                                    <tr>
                                        <th>Naam BMHK laboratorium</th>
                                        <th>Antwoordnummer</th>
                                        <th>Postcode</th>
                                        <th>Plaats</th>
                                    </tr>
                                    </thead>
                                    <tbody>
                                    <tr class="remove-row show-active" wicket:id="retouradressen">
                                        <td><span wicket:id="laboratorium.naam"></span></td>
                                        <td>
                                            <input class="input-large" type="text" wicket:id="adres.huisnummer">
                                        </td>
                                        <td>
                                            <input class="input-large" type="text" wicket:id="adres.postcode">
                                        </td>
                                        <td>
                                            <input class="input-large" type="text" wicket:id="adres.plaats">
                                        </td>
                                    </tr>
                                    </tbody>
                                </table>
                            </div>
                        </div>
                    </fieldset>
                </wicket:enclosure>

                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>Gekoppelde gemeentes</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span12">
                            <wicket:container wicket:id="gemeentes"></wicket:container>
                        </div>
                    </div>
                </fieldset>

                <div class="row-fluid">
                    <div class="span12">
                        <div class="form-actions btn-bottom">
                            <button wicket:id="annuleren" class="btn">Annuleren</button>
                            <button wicket:id="submit" class="btn btn-primary">Opslaan</button>
                        </div>
                    </div>
                </div>
            </form>

        </fieldset>
    </div>
</wicket:extend>
</html>
